Primary Care and the Next Phase of Health Care Reform

Michael Hochman, MD, MPH,is medical director for innovation at AltaMed Health Services, the largest independent federally qualified health center in the United States. AltaMed has enrolled more than 30,000 Southern Californians in Medi-Cal and Covered California, the state health care exchange. Hochman is an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program at the University of California, Los Angeles, and the U.S. Department of Veterans Affairs. Martin Serota, MD, is AltaMed’s chief medical officer.

Although the dust is still settling, most indicators suggest that the first wave of national health care reform was a success, particularly in California. More than 8 million Americans enrolled in commercial health plans under the Affordable Care Act, surpassing targets set by the Obama administration. Many more will qualify for plans under Medicaid expansion. As leaders at a community health center that serves a large population of low-income patients—many of whom currently lack coverage—we could not be happier about the new opportunities for our patients.

But we also know that the work is far from complete. Health care reform will only be a success if coverage expansion results in improvements in quality and efficiency, and better health for the population. As we know from the Massachusetts experience, it took time and a lot of effort for these benefits to ensue. Only now, several years after health care reform began in Massachusetts, are residents of the state starting to reap the benefits.

For this reason, health care organizations such as ours are rolling up our sleeves. We are energized by the successes of coverage expansion, but we want to ensure that these successes translate into better care for our patients.

We believe that the key to achieving this aim is improving our primary care delivery system. Numerous studies have demonstrated that health systems with robust primary care infrastructures provide higher quality care at lower costs than those with weak primary care systems.

At AltaMed, the largest federally qualified health center in the nation, we hope to further develop our primary care system through the patient-centered medical home (PCMH) model of care. This concept was formally introduced in 2007 by several leading primary care organizations including the American College of Physicians and the American Academy of Pediatrics. It emphasizes access to care, quality, continuity with a single provider, and care coordination, among other features.

The purpose of introducing the model was twofold. First, these organizations hoped to provide a framework and payment mechanism for health care systems like ours as we embark on primary care reform. Second, these organizations hoped to reinvigorate primary care by highlighting the ways in which high quality, accessible primary care services can bring value to patients and health systems.

At AltaMed, we have found the PCMH framework to be very helpful. For us, the model means taking a team-based approach in which our physicians and other providers work collaboratively with case managers, health educators, pharmacists, medical assistants, social workers, and other team members to collectively and holistically care for our patients. The model also means ensuring that our patients have access to appointments on nights and weekends and to 24/7 telephone advice; that they have a longitudinal relationship with a single primary care provider; and that their care is coordinated with hospitals and specialists. Although these principles may not sound revolutionary, the PCMH model has provided us with momentum to bring about improvement—which is particularly important in safety-net systems like ours that must serve an ever-growing population despite resource limitations.

The PCMH model has gotten some negative publicity recently. Specifically, a large PCMH demonstration published in the Journal of the American Medical Association showed only modest benefits of the model on quality and costs.

The JAMA study was important, but we believe many have interpreted it incorrectly. The focus of reform in the JAMA study was on achieving PCMH certification status—a list of check-boxes similar to regulatory requirements. While many of the items on the list are indeed important, reform efforts solely guided by a certification checklist are unlikely to result in meaningful improvements.

In contrast, other organizations aiming to transform their primary care systems using PCMH principles—for example, the Group Health Cooperative in Seattle and the Southcentral Foundation in Alaska—focused directly on improving key outcomes relevant to patients: quality of care, the patient experience, and their populations' health. These PCMH transformations were much more successful, not only in achieving the outcomes listed above but also in lowering overall costs.

The key lesson from these demonstrations, we believe, is that primary care reform can both improve quality and lower costs, but these efforts must be focused on what really matters to patients rather than a long list of complex and difficult-to-track measures. This is exactly what we are in the process of doing at AltaMed. Notably, our efforts will be greatly enhanced by the ongoing shift from traditional fee-for-service payments to one in which health systems are paid for managing populations and held accountable for quality and health outcomes.

In the coming months and years, there will be considerable challenges as newly insured patients begin accessing care in ways they never could before. There may be an initial spike in health care costs as these patients first begin using the health care system (this spike was noted in Massachusetts). In addition, insurance changes may create temporary disruptions in provider networks for patients, particularly in the commercial market.

In this new environment, the need for strong primary care will be greater than ever. As we attempt to meet the challenges, it will be essential that we take to heart the key lessons from the past, and keep the focus on patients and high quality, cost-efficient care. If we do this, we are confident that safety-net health systems like ours we will be able to deliver on our promise to provide everyone with the care they deserve.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

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